ATI real life RN : GI Bleed 3.0 Exit Exam.Nurse Esther listens to Ms. Lieberman's abdomen in all four quadrants and determines Ms. Lieberman's bowel sounds are hyperactive. Listen to the 4 audio clips. which of the following sounds is an expected finding for Ms. Lieberman:
A, B, C, D - answerC
...
Nurse Esther listens to Ms. Lieberman's abdomen in all four quadrants and determines
Ms. Lieberman's bowel sounds are hyperactive. Listen to the 4 audio clips. which of the
following sounds is an expected finding for Ms. Lieberman:
A, B, C, D - answerC
MS. Lieberman states she is feeling lightheaded and dizzy. her skin color is pale. which
of the following should be Nurse Esther's priority action?
A. measure Ms. Lieberman's vs
B. finish obtaining the admin hx
C. initiate oxygen at 2L/min via nasal cannula
D. elevate Ms. Lieberman's legs - answerA. measure Ms. Lieberman's vs
Ms. Lieberman reports feeling worse and her vital signs are: BP 94/56 mm Hg, pulse
110/min, RR 26/min, and SaO2 94%. Nurse Esther starts oxygen at 2 L/min. Which of
the following should be Nurse priority action?
A. recheck Ms. Lieberman's oxygen sat
B. check output from Ms. Lieberman's ostomy
C. lower the head of bed
D. send the AP to pick up blood - answerC. lower the head of bed
Nurse Esther is preparing to administer a unit of packed RBCs to Ms. Lieberman. Which
of the following actions should Nurse Esther perform prior to administering the blood?
A. infuse 0.9% sodium chloride IV solution remaining in the bag, prior to initiating the
transfusion
B. ask Ms. Lieberman if she has experienced a reaction with any previous blood
transfusions
C. ensure Ms. Lieberman's sister signs the consent form
D. perform verifications process with an AP - answerB. ask Ms. Lieberman if she has
experienced a reaction with any previous blood transfusions
rationale: a transfusion reaction can be caused by the dvlpmt of antibodies to the donor
leukocytes. this reaction is more likely to occur when a pt has had blood transfusions
before as well as a hx of prior blood transfusion rx.
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